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Bladder Augmentation and Continent Urinary Diversion in Boys with Posterior Urethral Valves

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Bladder Augmentation and Continent Urinary Diversion in Boys with Posterior Urethral Valves peDIATRIC urology bladder augmentation and continent urinary diversion in boys with posterior urethral valves Małgorzata baka-ostrowska Pediatric Urology Department Children’s Memorial Health Institute, Warsaw, Poland key worDs posterior urethral valves. Valve ablation in a neonate with sig- urinary bladder » valve bladder » bladder nificant reflux and a markedly trabeculated bladder can remodel itself remarkably within the first year of life. The persistence of augmentation hydronephrosis, bladder wall thickening, and trabeculation, as well as persistent elevation of serum creatinine can all be the manifes- abstraCt tation of persistent bladder outlet obstruction (BOO), so urethros- copy with repeated valve ablation is necessary. But what do you do Posterior urethral valve (PUV) is a condition that leads to if the obstruction is not anatomic? Carr and Snyder consider the characteristic changes in the bladder and upper urinary point at which a functional obstruction occurs and which manage- tract. Dysfunction of the bladder such as a hyperreflec- ment is reasonable [1]. They concluded that dysfunctions of the tive, hypertonic, and small capacity bladder as well as bladder such as a hyper-reflective, hypertonic, and small capacity sphincter incompetence and/or myogenic failure should bladder, as well as sphincter incompetence and/or myogenic failure be adequately treated. Poor compliance/small blad- should be adequately treated. der could be treated with anticholinergics, but bladder Myogenic failure with overflow incontinence and incomplete augmentation will probably be indicated. Although bladder emptying should be treated with time voiding, double bladder reconstruction with gastrointestinal segments voiding, α-blockers, and intermittent catheterization. can be associated with multiple complications, includ- Detrusor hyperreflexia with urinary frequency and urge urinary ing metabolic disorders, calculus formation, mucus incontinence (UUI) are usually managed with anticholinergics. production, enteric fistulas, and malignancy formation, Poor compliance/small bladder could be treated by anticholin- enterocystoplasty is still the gold standard. In contrast ergics, but most probably will need bladder augmentation. to a neuropathic or exstrophic bladder, augmentation The place and timing of augmentation cystoplasty in a ”valve of the valve bladder allows spontaneous voiding without bladder” have not yet been well established. In 1995, Kajbafzadeh significant residual urine in the majority of cases, but et al. reported their experience with augmentation cystoplasty some require CIC (clean intermittent cathterization). in 20 boys with previously treated PUV [2]. Urodynamic studies Augmentation cystoplasty is also an efficient approach confirmed poorly compliant, unstable bladders with low func- in those children who will require kidney transplantation tional capacities, which had failed to respond to anticholinergic in the future. treatment in all patients. The bladder was augmented with ileum in nine, stomach in seven, colon in two, and ureter in two cases. A Mitrofanoff channel was fashioned in six cases. Upper tract dilatation improved in 17 patients and remained stable in three. Posterior urethral valve (PUV) is a condition that leads to Of the patients, 17 are dry day and night. Eleven patients void characteristic changes in the bladder and upper tract. The bladder spontaneously without significant residual urine, seven are on CIC develops hypertrophic changes including hypertrophy and hyper- for residual urine of greater than 50 ml, and two are completely plasia of the detrusor muscle along with increased connective tis- dependent on catheterization. They concluded that augmentation sue. The ratio of muscle to connective tissue is the same as in the cystoplasty is a safe and effective method to achieve continence normal bladder but the type of collagen is different. The effects are in boys with a low capacity, poorly compliant bladder after valve visible as wall thickness, trabeculation, and diverticula. This results ablation that do not respond to medical management. In contrast in poor sensation, hyper-contractility and low compliance of the to the neuropathic and exstrophy bladder, the augmented valve bladder, and may contribute to poor emptying and incontinence. bladder allows spontaneous voiding without significant residual Almost all patients with PUV have severe hydroureteronephrosis urine in the majority of cases. Early intervention in these patients at the time of diagnosis with associated reflux in 50-70% of cases. may prevent deterioration in renal function. If there is no reflux the ureter and kidney are protected from the In reality, most of patients with “valve bladder” who qualified complete force of the bladder contraction, but if reflux occurs the for augmentation cystoplasty presented with renal insufficiency. entire pressure of the thickened and hyper-contractile bladder is The method of bladder augmentation is open to discussion. transmitted directly to the upper tract with severe consequences. Enterocystoplasty is the most popular but ureterocystoplasty Obstructive uropathy involves both glomerular and tubular injury. seems to be ideal. In 2007, Youssif et al. presented eight boys Glomerular injury occurs when high pressure results in decreased (mean age 5 years) with valve bladder syndrome after successful renal perfusion and filtration. It is partially reversible with pres- valve ablation [3]. When conservative treatment failed, uretero- sure reduction. Tubular damage results in failure to concentrate cystoplasty was scheduled. The entire ureter was folded and used and acidify the urine. It worsens with age despite early relief of in four boys after nephrectomy for a non-functioning kidney. obstruction; the resultant high urine volumes contribute to the The lower dilated ureter was used to augment the bladder, a deterioration of renal and bladder function in late childhood. transureteroureterostomy (TUU) was used in two patients, and re- The primary endoscopic ablation of the valves followed by implantation of the remaining ureter were performed in another a wait-and-see attitude is the most efficacious management of two patients. Bladder capacity and compliance were significantly Central european Journal of urology 2011/64/4 236 237 Central european Journal of urology 2011/64/4 MAłgorzata Baka-Ostrowska fig. 1. A 15 cm long sigmoid segment is isolated. fig. 2. Demucosalized sigmoid segment is folded in W-shape. fig. 3. Formed bowel is anastomized with the wide open bladder after continent fig. 4. reservoir is continent with adequate capacity. stoma creation (appendico-cutaneostomy according to Mitrofanoff). [7]. Hall confirmed that there is an increase in the urinary acid load improved in all cases. Hydroureteronephrosis improved in six boys with wasting of bony buffers even in the absence of frank acidosis (75%). Self-CIC was performed routinely in all cases after surgery, [8]. Such wasting may result in bone demineralization and can which was weaned off from as deduced from the voiding pattern cause retarded growth in children after augmentation cystoplasty. of the child. They concluded that ureterocystoplasty is an ideal Careful long-term follow up is obligatory because of meta- option for augmenting the hypocompliant bladder in boys with bolic disturbances and upper urinary tract changes as well as the valve bladder syndrome. The entire ureter or the dilated lower part potential risk of malignancy. Multiple cases of bladder cancer have can be used. The procedure avoids almost all the complications of been reported recently in young adults with a history of bladder enterocystoplasty. augmentation in childhood, but the mechanisms of developing In 2010, Fisang et al. confirmed the efficacy of ureterocysto- cancer in intestinal segments remain uncertain. The initiating event plasty in bladder augmentation, but enterocystoplasty is still the appears to occur soon after surgery. Epithelial proliferation at the method most frequently used while the ideal gastrointestinal seg- healing anastomosis in the presence of promoter carcinogens may ment remains controversial [4]. be a causing factor [9, 10]. Ileocystoplasty seems to be the most common technique for Gastrocystoplasty is an alternative to intestinal augmentation. augmentation [5]. This is because the ileum has been demonstrated The use of gastric patch was promising because of the quite easily as the least contracting bowel segment. However, using this bowel available tissue, lack of absorption of hydrogen ions, and bacteri- requires the isolation of a very long segment of ileum (usually cidal effect of acid secretion [11]. The wedge-shaped segment from 20-40 cm) depending on the volume needed. the greater curvature became popular in children. Unfortunately, Sigmoidocystoplasty allow reducing the length of bowel seg- the secretory nature of gastric mucosa results in two serious com- ment by even 15 cm, but strong unit contractions could come plications: hypokalemic, hypochlochloremic metabolic alkalosis forward [6]. and hematuria-dysuria syndrome. Also, local lesions could appear Metabolic complications related to the storage of urine within as perforation of the gastric segment and skin injury if urinary an intestinal segment is hyperchloremic acidosis. Mitchel and Piser continence is not sufficient to collect a big amount of urine dilut- noted that every patient after intestinal augmentation had an ing the gastric acid [12, 13]. increase
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